Clostridium tetani : Diagnosis, treatment and Prevention
Diagnosis of tetanus
Based entirely on clinical findings:
- History of an injury
- Particularly one in which either soil or fecal material has been introduced
- 6-12 days before the onset of typical clinical findings.
- Wound should be cultured in suspected cases.
Other laboratory findings may be –
- Leukocytosis
- Muscle enzyme levels may be raised
- Electromyogram
- Show continuous discharge of motor units a
- Shortening or absence of the silent interval.
Treatment of tetanus
- Treatment of tetanus includes :
1. Antimicrobial therapy :-
- Eradicate vegetative cells
- Penicillin and metronidazole are first line drugs.
- Clindamycin and erythromycin are alternatives for penicillin – allergic patients.
- Tetracycline is not used.
2. Antitoxin :-
- Neutralize circulating toxin.
- All wounds must be thoroughly cleaned soon after injury
- Human tetanus immune globuline (TIG) is the preparation of choice.
- Administered within time it neutralizes tetanus toxin and significantly lowers the mortality
- Serious wound + uncertain about immunization should receive both
- Tetanus toxoid (active immunity)
- Tetanus immune globulin (Passive immunity)
Control of muscle spasms :-
- Muscle spasms cause laryngospasm or sustained contraction of ventilatory muscles.
- Therefore painful and life threatening.
- Benzodiazepines (Diazepam, lorazepam, midazolam) are used most commonly.
- Alternatives are Barbiturates and chlorpromazine.
- Mechanical ventilation used for spasms unresponsive to medications.
- Other agents include propofol, dantrolene, intrathecal baclofen, succinylcholine and magnesium sulfate.
Respiratory care :-
- Intubation or tracheostomy, with or without mechanical ventilation may be required.
Autonomic dysfunction :-
- For sympathetic overactivity labetalol, esmolol or clonidine may be used.
Vaccine :-
- Patient recovering from tetanus should be actively immunized.
Prevention
Active immunization
- Protective level of antitoxin > 0.01 IU/ml serum
- Active immunity offered by tetanus toxoid is effective in 100% of the patients
- Adsorbed toxoid are more beneficial
- Should never freeze
Monovalent Vaccine:
- 2 dose of purified tetanus toxoid (IT) should be given at interval of 1-2 month
- Ist booster after 1 year of 2nd dose.
- 2nd booster after 5 years of 3rd dose.
Combined Vaccine :
- DPT .
Passive immunization :
- Human tetanus hyper immunoglobulin (TIG) is best prophylactic to use.
- Toxin already bound to neural tissue is not affected.
Combined active and passive immunization:
- Patient is given TIG in one arm
- TT in other arm
- Followed by another dose of TT 6 weeks later and third dose 1 year later.
- TIG contraindicated during pregnancy.
- The purpose of antitoxin is for immediate temporary protection
- The purpose of tetanus toxoid is for long lasting protection
- TT is useful even after 12 hours have elapsed following injury.
Pregnancy
Primigravida
- Tetanus toxoids appear safe during pregnancy
- Administered intramuscularly.
- 0.5 ml tetanus toxoid is given at 6 weeks interval for 2 times
- The first one to be given between 16-24 weeks.
Multigravida (completely immunized in last 5 years):
- 1 booster dose is sufficient
Multigravida (partially immunized in previous pregnancy in last 5 years):
- 2 doses, 1 month apart, after I trimester.
Multigravida (unimmunized in previous pregnancy in last 5 years):
- 2 doses, I month apart, after I trimester
Multigravida (completely immunized in previous pregnancy earlier than 5 years):
- 2 doses, I month apart, after I trimester.
Exam Important
Diagnosis of tetanus
- Muscle enzyme levels may be raised
Treatment of tetanus
- Antimicrobial therapy
- Antitoxin :-
- Human tetanus immune globuline (TIG) is the preparation of choice.
- Administered within time it neutralizes tetanus toxin and significantly lowers the mortality
- Serious wound + uncertain about immunization should receive both
- Tetanus toxoid (active immunity)
- Tetanus immune globulin (Passive immunity)
Prevention
Active immunization
- Protective level of antitoxin > 0.01 IU/ml serum
- Active immunity offered by tetanus toxoid is effective in 100% of the patients
- Adsorbed toxoid are more beneficial
- Should never freeze
Monovalent Vaccine:
- 2 dose of purified tetanus toxoid (IT) should be given at interval of 1-2 month
- Ist booster after 1 year of 2nd dose.
- 2nd booster after 5 years of 3rd dose.
Combined Vaccine :
- DPT .
Passive immunization :
- Human tetanus hyperimmunoglobulin (TIG) is best prophylactic to use.
- Toxin already bound to neural tissue is not affected.
Combined active and passive immunization:
- Patient is given TIG in one arm
- TT in other arm
- Followed by another dose of TT 6 weeks later and third dose 1 year later.
- TIG contraindicated during pregnancy.
- The purpose of antitoxin is for immediate temporary protection
- The purpose of tetanus toxoid is for long lasting protection
- TT is useful even after 12 hours have elapsed following injury.
Pregnancy
Primigravida
- Tetanus toxoids appear safe during pregnancy
- 0.5 ml tetanus toxoid is given at 6 weeks interval for 2 times
- The first one to be given between 16-24 weeks.
Multigravida (completely immunized in last 5 years):
- 1 booster dose is sufficient
Multigravida (partially immunized in previous pregnancy in last 5 years):
- 2 doses, 1 month apart, after I trimester.
Multigravida (unimmunized in previous pregnancy in last 5 years):
- 2 doses, I month apart, after I trimester
Multigravida (completely immunized in previous pregnancy earlier than 5 years):
- 2 doses, I month apart, after I trimester.
